Stroke survivors with severe upper limb disability have a poor prognosis for functional recovery. The aim of this thesis was to explore the potential for stroke survivors with severe upper limb disability to improve in function during inpatient rehabilitation, by examining the contribution of factors related to the individual, and their training. To address this aim seven studies were completed.
The first phase of the thesis explored the contribution of the individual to functional recovery. Study 1 consisted of a systematic review to identify individual factors predictive of functional recovery. To address limitations of previous reviews, factors predictive of 1) recovery at discharge versus follow-up; and 2) good functional outcome versus functional change were examined. From a review of 84 studies, the key factor identified was presence of residual movement, which predicted better activities of daily living at discharge and follow-up and upper limb function at follow-up only. No factors predicted a change in function. These findings indicated that functional recovery was often considered to be achievement of a good functional outcome rather than functional change.
As functional change may be more relevant for stroke survivors with severe motor disability, Study 2 explored the rehabilitation potential of 618 stroke survivors according to achievement of a minimal clinically important difference (MCID) in motor disability after inpatient rehabilitation. Stroke survivors with severe motor disability demonstrated a significant change in function (p <0.0001) and most achieved a MCID (57% and 72% respectively). These findings demonstrated that stroke survivors with severe motor disability can achieve a meaningful change in function as a result of inpatient rehabilitation. However, these findings were from stroke survivors who had been deemed to have potential to benefit from inpatient rehabilitation.
To investigate why some stroke survivors with severe disability are considered suitable and others not, Study 3 explored the decision-making process used by consultant medical officers, via an online survey. Factors related to the stroke survivor’s physical function, along with the presence of social support networks favoured admission to inpatient rehabilitation. The presence of behavioural and cognitive impairments disfavoured admission. Continued functional gains favoured continuation of rehabilitation, while a plateau favoured cessation. Thus, early and continued return of movement was found to be critical for a good functional outcome and access to and continuation of inpatient rehabilitation. This suggests that stroke survivors with little to no residual movement are most disadvantaged.
The next phase of the thesis examined the impact of training on functional recovery. While it was assumed that training leads to functional recovery, the additional benefit gained from use of training elements (e.g. feedback) was unclear. Study 4 aimed to identify the beneficial effect of a single training element. Thirty-six randomized clinical trials across nine training elements were reviewed. Only manipulation of degrees of freedom and use of mental practice enhanced functional recovery. It is possible however, that the benefits of training elements are intervention specific or arise from a cumulative effect of a number of training elements.
The potential for functional recovery in response to training is also likely to be dependent on dose and content of training. As the usual dose and content of therapy for stroke survivors with severe upper limb disability had not been evaluated, Study 5 was undertaken. Therapist-recorded logs demonstrated that occupational therapy provided a higher dose of upper limb therapy when compared to physiotherapy, and therapy was more often targeted at impairment rather than activity-related deficits. Thus, stroke survivors with severe upper limb disability may not be participating in an appropriate dose or content of therapy to promote best functional recovery.
SMART Arm training is one intervention that can enhance training dose and content. It enables intensive and repetitive practice of reaching in stroke survivors with severe upper limb disability. Recognising the potential for individual factors to influence functional recovery, Study 6 was undertaken to explore the contribution of these factors during upper limb therapy, which included SMART Arm training. Consistent with previous findings, greater residual movement of the upper and lower limb predicted greatest upper limb functional outcome and functional change.
As the use of training elements to accelerate functional recovery may be intervention specific, Study 7 explored how trainers used training elements during SMART Arm training. Trainers provided a larger dose of training that was incrementally progressed with stroke survivors who had residual movement at baseline or achieved a MCID in upper limb function than those who did not. Therefore, in the absence of movement, gaining movement would appear critical.
In conclusion, stroke survivors with severe upper limb disability have potential to benefit functionally from inpatient rehabilitation, particularly if they have residual movement. In the absence of residual movement, it is critical to gain movement so stroke survivors with severe upper limb disability can drive their recovery in the long-term.